Application for Electrolysis Facility Licensure

Electrolysis Facility Information

An “electrology facility” is that portion of any establishment or place wherein electrolysis is performed.

“Electrolysis” means the removal of hair using equipment and devices approved by the Board of Medicine as further outlined in section (s.) 478.42(5), Florida Statutes (F.S.), and Rule 64B8-56.002, Florida Administrative Code (F.A.C.).

“Electrologist” means a person who engages in the practice of electrolysis and is licensed under chapter (ch.) 478, F.S.

All electrolysis training programs must be licensed as an electrolysis facility.

Facilities must be licensed prior to opening and offering electrolysis services.

No license may be transferred from one license to the name of another person. If a facility is sold, the new owner must apply to the department for licensure and no electrolysis services may be performed in the facility after the sale until the new owner has received the required license from the department. A person purchasing an electrology facility may apply to the department for licensure prior to the date of purchase. Prior to moving, existing facility owners transferring to a new location must submit an “Application for Transfer of Electrolysis Facility Location.”

Florida licensed medical doctors and osteopathic physicians who are operating an electrolgy facility on the premises of their medical practice location are not required to obtain an electrology facility license. Likewise, electrologists employed by physicians licensed under ch. 458 or 459, F.S. and practicing at the physician’s medical practice are not required to obtain an electrology facility license. Any change in employment status in an exempt facility (such as changing from employee to independent contractor), requires the council office to be notified to determine whether licensure will be required.

Laser & Light-based Hair Removal Requirements:

Electrologists who are to perform laser and light-based hair removal in the facility, must be actively licensed with the Department of Health and meet requirements specified in Rule 64B8-56.002, F.A.C., including providing services only under the direct supervision of a medical doctor or osteopathic physician and submission of the required protocols to the Florida Electrolysis Council office. For additional information visit our website at http://www.floridahealth.gov/ licensing-and-regulation/electrolysis/laser/index.html

DH‐MQA 1213, Revised 6/2020, Rule 64B8‐51.006, F.A.C. Page 2 of 13 Application for Electrolysis Do Not Write in this Space Facility Licensure For Revenue Receipting Only Electrolysis Council P.O. Box 6330 Tallahassee, FL 32314-6330 Fax: (850) 414-6860 Email: [email protected] Before applying for licensure, ensure that your facility meets all required equipment, safety, and sanitation requirements. All requirements are outlined in Rule 64B8-51.006, Florida Administrative Code (F.A.C.) See the checklists after the application for more information.

Select one method of licensure: Total fee of $305.00 includes the following: Application Fee $100.00 New Electrolysis Facility (6502) $305.00 Inspection Fee $100.00 Licensure Fee $100.00 New Ownership of Existing Facility (6502) $305.00 Unlicensed Activity Fee $5.00

Fees must be paid in the form of a cashier’s check or money order, made payable to the Department of Health. An applicant who is denied licensure or withdraws their application is entitled to a $105.00 (Licensure Fee and Unlicensed Activity Fee) refund. Requests to withdraw or for a refund must be made in writing. Fees are refundable for up to three years from the date of receipt.

1. BUSINESS INFORMATION

Corporate Name: ______

Doing Business As (D/B/A) (as it should appear on license): ______

______Mailing Address Suite No. City

______State ZIP Telephone (Input without dashes)

______Physical Location of Facility: Suite No. City (This address will be posted on the Department of Health’s website)

______State ZIP Facility Telephone Facility Fax (Input without dashes) (Input without dashes)

Practice Modality Type: Epilator Hair Removal Only Laser & Light-Based Hair Removal/Reduction Only* Both Modalities * Electrologists may perform laser and light-based hair removal only if they follow the requirements specified in Rule 64B8-56.002, F.A.C. Review the rule and additional information regarding these requirements at http://www.floridahealth.gov/licensing-and-regulation/electrolysis/laser/index.html

Email Notification: To be notified of the status of your application by email, check the “Yes” box and fill in your email address on the line provided. If you choose to be notified via email you will be responsible for checking your email regularly and updating your email address with the board office.

Yes No Email Address: ______Under Florida law, email addresses are public records. If you do not want your email address released in response to a public records request, do not provide an email address or send electronic mail to our office. Instead contact the office by phone or in writing.

DH‐MQA 1213, Revised 6/2020, Rule 64B8‐51.006, F.A.C. Page 3 of 13 Corporate Name: ______2. OWNERSHIP INFORMATION

A. Type of Ownership: (choose only one) Individual Corporation Partnership Sole Proprietorship Other: ______

B. Owner Name: ______

______Mailing Address Apt. No. City

______State ZIP

C. Is the owner a Florida Department of Health licensed electrologist? Yes No

If “Yes,” provide the license number: EO ______

D. If ownership type is a corporation, list all corporate officers (attach additional sheet if necessary):

Officer Name Officer Title Telephone Number*

______Name of Authorized Corporate or Facility Representative Additional Telephone Number* * Input without dashes E. Has the facility been previously owned? Yes No

If “Yes,” provide the following:

Name of Previous Owner: Name of Facility: Facility License Number: EP

F. Has any owner/officer of the proposed establishment ever held an electroysis facility license in Florida? Yes No

If “Yes,” provide the following information (attach additional sheets if necessary):

Facility Name Facility License # Current Status

DH‐MQA 1213, Revised 6/2020, Rule 64B8‐51.006, F.A.C. Page 4 of 13 Corporate Name: ______

3. FACILITY INFORMATION

A. Anticipated Opening Date: ______MM/DD/YYYY

B. Anticipated Hours of Operation: List actual hours. If your facility will not be open, select N/A. If by appointment only, select “Appt.”

Weekday Opening Time Closing Time Other Monday AM PM AM PM N/A Appt Tuesday AM PM AM PM N/A Appt Wednesday AM PM AM PM N/A Appt Thursday AM PM AM PM N/A Appt Friday AM PM AM PM N/A Appt Saturday AM PM AM PM N/A Appt Sunday AM PM AM PM N/A Appt

C. Indicate the type of building where the facility will be located:

Cosmetology Salon/Barber Shop Health Club/Spa Home/Residence Medical Facility Office Building Physician's Office Shopping Center/Department Store Other: ______

If you checked either “Medical Facility” or “Physician’s Office,” will you be employed by a medical doctor or osteopathic physician and practicing in his or her medical practice location? Yes No

If “Yes,” have the physician or medical facilities complete the “Employment Verification Request” form found at the end of the application.

DH‐MQA 1213, Revised 6/2020, Rule 64B8‐51.006, F.A.C. Page 5 of 13 Corporate Name: ______

D. Provide the following information for all electrologists who will be practicing in the facility, including the facility owner if the owner is still or will be a licensed electrologist. Attach additional sheets if necessary.

For Licensed Electrologists Who Completed ONLY the Needle-Type Epilation Training Program:

Name: License #: EO Will the licensee be providing laser/light-based hair removal services? Yes No If “Yes,” provide laser and light-based qualifying information, pursuant to Rule 64B8-56.002, F.A.C. below. 30-hour CE Completion Date: CME Completion Date: Supervising Physician's License #: Physician/Electrologist Protocol Completion Date:

For Licensed Electrologists Who Completed the Needle-Type Epilation, Laser, and Light-Based Training Program:

Name: License #: EO Will the licensee be providing laser/light-based hair removal services? Yes No If “Yes,” provide laser and light-based qualifying information, pursuant to Rule 64B8-56.002, F.A.C. below. Combined Program Graduation Date: Combined Epilator, Laser, and Light-based Exam Date (approximate): Supervising Physician's License #: Physician/Electrologist Protocol Completion Date:

Documentation of completed requirements may be attached for upload to the electrologist’s licensure record.

DH‐MQA 1213, Revised 6/2020, Rule 64B8‐51.006, F.A.C. Page 6 of 13 Corporate Name: ______

4. DISCIPLINE HISTORY A. Has any owner/officer of the proposed establishment ever had a license or certificate of registration to practice electrology or any other licensed profession or an electrology facility license revoked, suspended or otherwise acted against (including but not limited to probation, fine, reprimand, or surrender of a license) in a disciplinary proceeding or in response to an investigation in any state? Yes No

B. Has any owner/officer ever been issued a cease and desist agreement or citation for the unlicensed practice of electrology or operating an establishment without a license? Yes No

C. Has any owner/officer of the proposed establishment ever had a license or certificate of registration to practice electrology or any other licensed profession or an electrology facility license denied for any reason in any state? Yes No

D. Is there currently pending against any owner/officer of the proposed establishment a complaint or investigation in any state/jurisdiction for professional conduct or competence? Yes No If you responded “Yes” to any of the questions in this section, complete the following: Action Date Under Name of Agency State Final Action (MM/DD/YYYY) Appeal? Y N Y N Y N If you responded “Yes” to any of the questions in this section, you must provide the following:

A written self-explanation, describing in detail the circumstances surrounding the disciplinary action.

A copy of the Administrative Complaint and Final Order. 5. CRIMINAL HISTORY Has the applicant or any officer/owner ever been convicted of, or entered a plea of guilty, nolo contendere, or no contest to any crime in any jurisdiction other than a minor traffic offense? You must include all misdemeanors and felonies, even if adjudication was withheld. Reckless driving, driving while license suspended or revoked (DWSLR), driving under the influence (DUI) or driving while impaired (DWI) are not minor traffic offenses for purposes of this question. Yes No If you responded “Yes” in this section, complete the following: Date Under Offense Jurisdiction Final Disposition (MM/DD/YYYY) Appeal? Y N Y N Y N

If you responded “Yes,” you must provide the following: A written self-explanation, describing in detail the circumstances surrounding each offense; including date, city and state, charges and final results. Final Dispositions and Arrest Records for all offenses. The Clerk of the Court in the arresting jurisdiction will provide you with these documents. Unavailability of these documents must come in the form of a letter from the Clerk of the Court. Completion of Sentence Documents. You may obtain documents from the Department of Corrections. The report must include the start date, end date, and that the conditions were met.

DH‐MQA 1213, Revised 6/2020, Rule 64B8‐51.006, F.A.C. Page 7 of 13 Corporate Name: ______

6. CRIMINAL AND MEDICAID/MEDICARE FRAUD QUESTIONS IMPORTANT NOTICE: Applicants for licensure, certification, or registration and candidates for examination may be excluded from licensure, certification, or registration if their felony convictions fall into certain timeframes as established in s. 456.0635(2), F.S. 1. Has the applicant or any principal, officer, agent, managing employee, or affiliated person of the applicant ever been convicted of, or entered a plea of guilty or nolo contendere, regardless of adjudication, to a felony under chapter (ch.) 409, F.S. (relating to social and economic assistance), ch. 817, F.S. (relating to fraudulent practices), ch. 893, F.S. (relating to drug abuse prevention and control) or a similar felony offense(s) in another state or jurisdiction? Yes No If you responded “No” to the question above, skip to question 2. a. If “Yes” to 1, for the felonies of the first or second degree (or the equivalent level of felony in another state or jurisdiction), has it been more than 15 years from the date of the plea, sentence, and completion of any subsequent probation? Yes No b. If “Yes” to 1, for the felonies of the third degree (or the equivalent level of felony in another state or jurisdiction), has it been more than ten years from the date of the plea, sentence, and completion of any subsequent probation? This question does not apply to felonies of the third degree under s. 893.13(6)(a), F.S. or similar felony offense committed in another state or jurisdiction. Yes No c. If “Yes” to 1, for the felonies of the third degree (or the equivalent level of felony in another state or jurisdiction) under s. 893.13(6)(a), F.S. or a similar felony offense committed in another state or jurisdiction has it been more than five years from the date of the plea, sentence, and completion of any subsequent probation? Yes No d. If “Yes” to 1, has the applicant or any principal, officer, agent, managing employee, or affiliated person of the applicant successfully completed a drug court program that resulted in the plea for the felony offense being withdrawn or the charges dismissed? Yes No

2. Has the applicant or any principal, officer, agent, managing employee, or affiliated person of the applicant ever been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, to a felony under 21 U.S.C. ss. 801-970 or 42 U.S.C. ss. 1395-1396 (relating to public health, welfare, Medicare and Medicaid issues)? Yes No

If you responded “No” to the question above, skip to question 3.

a. If “Yes” to 2, is the date of application more than 15 years after the sentence and any subsequent period of probation? Yes No

3. Has the applicant or any principal, officer, agent, managing employee, or affiliated person of the applicant been terminated for cause from the Florida Medicaid Program pursuant to s. 409.913, F.S.? Yes No

If you responded “No” to the question above, skip to question 4.

a. If “Yes” to 3, has the applicant or any principal, officer, agent, managing employee, or affiliated person of the applicant been reinstated and in good standing with the Florida Medicaid Program for the most recent five years? Yes No

DH‐MQA 1213, Revised 6/2020, Rule 64B8‐51.006, F.A.C. Page 8 of 13 Corporate Name: ______

4. Has the applicant or any principal, officer, agent, managing employee, or affiliated person of the applicant been terminated for cause, pursuant to the appeals procedures established by the state, from any other state Medicaid program, unless the applicant has been in good standing with a state Medicaid program? Yes No

If you responded “No” to the question above, skip to question 5.

a. If “Yes” to 4, has the applicant or any principal, officer, agent, managing, employee, or affiliated person of the applicant been in good standing with a state Medicaid program for the most recent five years? Yes No

b. If “Yes” to 4, did the termination occur at least 20 years prior to the date of this application? Yes No

5. Is the applicant or any principal, officer, agent, managing employee, or affiliated person of the applicant currently listed on the United States Department of Health and Human Services’ Office of the Inspector General’s List of Excluded Individuals and Entities (LEIE)? Yes No

a. If “Yes” to 5, is the applicant, principal, officer, agent, managing employee, or affiliated person of the applicant listed because the individual defaulted or is delinquent on a student loan? Yes No

b. If “Yes” to 5.a., is the student loan default or delinquency the only reason the individual is listed on the LEIE? Yes No

If you responded “Yes” to any of the questions in this section, you must provide:

A written self-explanation for each question including the county and state of each termination or conviction, date of each termination or conviction, and copies of supporting documentation.

Supporting documentation including court dispositions or agency orders where applicable.

All documentation must be submitted to:

Electrolysis Council 4052 Bald Cypress Way Bin C‐05 Tallahassee, FL 32399‐3255

DH‐MQA 1213, Revised 6/2020, Rule 64B8‐51.006, F.A.C. Page 9 of 13 Corporate Name: ______

7. APPLICANT SIGNATURE

I, ______, state that I am the owner of the Electrology Facility referred to in the foregoing application and any supporting documentation are true and accurate.

I have carefully read the instructions and questions in the foregoing application had answered them completely, without reservations of any kind.

I understand that Florida law requires me to immediately inform the board of any material change in any circumstances or condition stated in the application which takes place between the initial filing and the final granting or denial of the license and to supplement the information on this application as needed.

I hereby acknowledge that I have read and understand ch. 478, and rules 64B8-50 through 56, F.A.C.

Section 456.013(1)(a), F.S., provides that an incomplete application shall expire one year after the initial filing with the department.

Signature ______Date ______Owner of establishment MM/DD/YYYY

Inspections

Upon review of a complete application, the Department of Health will arrange to send an inspector to the facility to determine compliance with the law and rules. The most current inspection form is available at: http://www.floridahealth.gov/licensing-and-regulation/enforcement/inspection-program/inspection-forms.html

Inspectors will provide a copy of the completed inspection form to the applicant. The form must be displayed in a conspicuous location within the facility along with a copy of Rule 64B8-51.006, F.A.C.

Facilities that meet all requirements and pass the inspection will be issued a license. Facilities which fail to meet requirements in an inspection will be denied licensure in writing listing the specific requirement(s) not met. No applicant denied licensure will be precluded from reapplying for licensure.

Practicing without a License

Practicing in or allowing the practice of electrolysis in an unlicensed facility is punishable by a fine from $250.00 to $5,000.00 and other disciplinary penalties up to denial of licensure of the facility. The electrologist as well as the facility owner may be fined and/or disciplined by the Board of Medicine.

Renewal

All facility licenses expire on May 31st of every even numbered year. The expiration date is printed on the license. Failure to renew the facility license by May 31st of every even numbered year will render the license delinquent. Failure to renew within 6 months of the expiration date will render the license null and void. The facility will no longer be licensed, and all electrolysis practice must cease. In order to regain licensure after a license becomes null and void, the owner must completely re-apply and be inspected before the license can be issued and practice at the facility can begin.

DH‐MQA 1213, Revised 6/2020, Rule 64B8‐51.006, F.A.C. Page 10 of 13 Electrolysis Facility Safety and Sanitary Requirements Checklist Compliance with these requirements will be verified by Department of Health inspectors prior to initial licensure. Licenses will be issued upon notification to the council office of the facility passing inspection. No inspection will be passed, and no license issued to any electrolysis facility that does not meet the requirements outlined below. A. All facilities are required to have the following supplies and equipment:

A clean toilet and sink with hot and cold running water available to the electrolysis facility must be kept in working order when the facility is open for business;

A treatment table or treatment chair with non-porous surface capable of being disinfected;

Client service area must allow for protection from view of the public, and any other clients at the facility, at the time of service. This requirement does not apply to training programs engaged in training students in electrolysis;

Disposable paper drapes or sanitary cloth drapes stored in closed container compartment;

Sanitary waste receptacles for the disposal of used gloves, paper supplies, cotton balls, and other noninfectious items;

Single use, disposable towels;

A treatment lamp or magnifier lamp capable of being cleaned with disinfectant;

A magnifying device which must be a magnifier lamp, optical loupe, or microscope capable of being cleaned and disinfected;

Tuberculocidal hospital grade disinfectant registered by the Environmental Protection Agency, household bleach or wiping cloths pre-saturated with disinfectant for wiping non-porous surfaces;

Betadine, 3% U.S. Pharmaceutical grade hydrogen peroxide, or 70% isopropyl alcohol, or wrapped single use wipes saturated with 70% isopropyl alcohol;

Clean, non-sterile materials such as cotton balls, cotton strips, cotton swabs, gauze pads, and gauze strips;

If cloth towels are used, they must be cleaned prior to use on each client and stored in a closed container or compartment. Used cloths must be kept in a separate closed container;

A holding container for soaking and cleaning contaminated instruments; and

Non-sterile disposable examination gloves.

B. Epilator-Only Hair Removal Facilities are required to have all the supplies and equipment listed in Section A. above as well as the following:

An FDA registered needle-type epilation device in working order;

Clean and sterile needles/probes and forceps/tweezers;

Needle holder tips;

A sharps container for disposal of used needles/probes, as defined in Rule 64E-16, F.A.C., effective December 2, 2015, which is hereby incorporated by reference and can be obtained at https://www.flrules.org/gateway/ChapterHome.asp?Chapter=64-16;

Covered containers for needles/probes and forceps/tweezers which containers are capable of being cleaned and sterilized;

A sterilizer which must be either an autoclave or a dry heat sterilizer, and color change indicators for use with either sterilizer. The endodontic dry heat “glass bead sterilizer” must not be used for instrument sterilization; and

Quarterly records of sterilizer biological tests monitoring (not applicable on first inspection for licensure of a new facility – required for all future inspections after license is issued.) DH‐MQA 1213, Revised 6/2020, Rule 64B8‐51.006, F.A.C. Page 11 of 13 C. Laser or Light Based-Only Hair Removal Facilities are required to have all supplies and equipment listed in Section A. above as well as the following: For licensed electrologists who completed a council-approved needle-type epilation training program, the following qualifying information pursuant to Rule 64B8-56.002, F.A.C.:  Proof of certification of 30 hours of continuing education in laser and light-based hair removal and reduction from a provider approved pursuant to Rule 648-52.004, F.A.C. A listing of approved providers may be found by using the “Course Search” function for Florida Electrologists at www.cebroker.com; and  Proof of having passed the Society of Clinical and Medical Hair Removal test for certification as a Certified Medical Electrologist. For licensed electrologists who completed a council-approved combined needle-type epilation, laser and light-based hair removal training program, the following qualifying information pursuant to Rule 64B8- 56.002. F.A.C.:  Proof of completion from a combined training program; and  Proof of having passed the epilator, laser, and light-based combined exam. For devices required to be registered, proof of registration for each laser or light-based device in use at the facility as required by s. 501.122, F.S.; Written designation of laser safety officer; A room or rooms specifically designated for use of the laser or light-based equipment where all use of such equipment must take place; Sign on door of laser room identifying when laser or light-based equipment is in use; Lock on door of laser room; Protective eyewear capable of being cleaned and disinfected must be used by all persons in laser room during operation of laser or light-based equipment; Fire extinguisher in vicinity of laser room; Cold water and ice; and The written protocols required by Rule 64B8-56.002(4)(a), F.A.C. Electrology Facility Document Requirements Checklist- All Facility Types The following requirements must be fulfilled by an Electrology facility in order to pass an inspection. See Rule 64B8-51.006(4), F.A.C., for more information. Compliance with these requirements will be verified by Department of Health inspectors prior to initial licensure. Licenses will be issued upon notification to the council office of the facility passing inspection. No inspection will be passed, and no license issued to any electrolysis facility that does not meet the requirements outlined below. The following documents must be displayed in an area that is visible to the general public entering the facility: 1. The electrology facility license. 2. The current license of the electrologist(s). 3. The most recent inspection sheet from the Department of Health. 4. A current copy of rule 64B8-51.006, F.A.C. An appointment book must be maintained and kept on the electrology facility premise which lists the names of each person who has received electrolysis treatment. The appointment book must be maintained for four years. The appointment book may be electronic record. Important: Once a facility has been issued a license under one modality (epilator or laser-light based), to add or switch modality of hair removal services being provided, the “Application for Inspection for Adding or Switching to a New Electrology Modality” (Form DH-MQA 5008-09/15) must be submitted. The facility must pass an inspection prior to implementing the new modality.

DH‐MQA 1213, Revised 6/2020, Rule 64B8‐51.006, F.A.C. Page 12 of 13 Complete verifications must be mailed directly from the verifying agency to:

Electrolysis Council 4052 Bald Cypress Way Bin C‐05 Tallahassee, FL 32399‐3255

Electrolysis Council Employment Verification Request This form is for the purpose of documenting an exemption from facility licensure based on the following rule.

Rule 64B8-51.006(2)(b), F.A.C., provides, in part, as follows: “…physicians licensed under Chapter 458 or 459, F.S., who are operating an electrology facility on the premises of their medical practice location are not required to obtain an electrology facility license and electrologists employed by physicians licensed under Chapter 458 (Medical Doctors licensed under the Board of Medicine) or Chapter 459 (Osteopathic Physicians licensed under the Board of Osteopathic Medicine), F.S., and practicing at the physician’s medical practice location are not required to obtain an electrology facility license.”

Part I: To be completed by Practitioner Seeking Facility Exemption (electrologist, if employed by physician or physician if claiming exemption for self)

Name: ______

Address: ______

Social Security Number: ______

I hereby authorize release of any information regarding my employment to the Florida Electrolysis Council.

Applicant Signature: ______Date: ______MM/DD/YYYY

Part II: To be submitted by Verifier

All verifications must be in English and include the following criteria: * Typed on an official letterhead * Contact Information * Signature, date, and title of the verifying agent

The following information must be included in all verifications: * Electrologist Name * Electrologist Social Security Number * Position Title * Dates of Employment (MM/DD/YYYY to MM/DD/YYYY) * Eligible for Rehire? (If not eligible for rehire, explain why) * Physician’s Name * Physician’s License # * Place of Employment * Business Address o Is this address the medical practice location on file with the Florida Department of Health for the Physician? Yes No

Any future changes impacting the applicant’s status should be promptly reported to the council office at [email protected] or mailed to the Florida Electrolysis Council at the address listed at the top of this form, to determine whether the change will require pursuit of an electrolysis facility license. DH‐MQA 1213, Revised 6/2020, Rule 64B8‐51.006, F.A.C. Page 13 of 13